Patients are not doctors' equals

Barts and The London, Queen Mary School of Medicine and Dentistry, London EC1A 7BE

St James's University Hospital, Leeds LS9 7TF

Royal Edinburgh Hospital, Edinburgh EH10 5HF

EDITOR—Smith in his editorial on the discomfort of patient power says that there is no “truth” defined by experts.1 Coulter reports that doctors and patients are equals with different expertise.2 The government's working group on chronic fatigue syndrome and myalgic encephalomyelitis wove patients' assertions into the scientific research in its report.3

It is absurd to say that there is no truth defined by experts, that patients are equals, or allow patients to define conditions and treatment. Although criticism of medical hubris is important, this is a denial of the nature of medicine. Clinical effectiveness depends on understanding the patient's beliefs and expectations. Patients are, however, not equals, and their beliefs do not have the ontological status of medical knowledge.

Denial of the status of doctors and of medicine's tradition of research is false democracy. It is an attempt to avoid destructive envy. Destructive envy denigrates and spoils that which is needed, biting the hand that feeds us or cutting off one's nose to spite one's face. More than other professional groups, doctors are envied. Partly this derives from the inequality of the relationship between doctors and patients. It can be difficult to tolerate powerlessness, ignorance, dependence, needing help, and being helped. For doctors it is difficult having their attempts to help spoiled by the patient. It is easier to feign uncertainty or powerlessness and comply with patients' demands. But this attempt to avoid envy leads talented doctors to deny their skills, knowledge, and authority. Placatory goodwill abounds but addressing the painful problems of the patient is hindered.4

Often patients come demanding investigations, referrals, or treatments. Acquiescence leads to further demands and feelings of desperation in the doctor. Attendant is the risk of unnecessary, harmful interventions, just to do something.5 One can endlessly improve one's consulting skills or be more patient centred, but the envy doesn't go away. These patients strive to undermine their doctor's skill, knowledge, and concern. This is not restricted to just a minority of manifestly antisocial patients.

Understanding the destructive forces in the doctor-patient relationship is essential. The bland pseudodemocratic niceties in the BMJ are no substitute for understanding the dynamics of the consultation or the legal and social changes affecting the health service, neither do they enable us to work in the best interests of our patients.

Power sharing is not a takeover bid

Barts and The London, Queen Mary School of Medicine and Dentistry, London EC1A 7BE

St James's University Hospital, Leeds LS9 7TF

Royal Edinburgh Hospital, Edinburgh EH10 5HF

EDITOR—Smith discussed the discomfort of patient power.1 Having declared a conflict of interest—I am one of the clinicians who resigned from the working group that reported to the chief medical officer on chronic fatigue syndrome and myalgic encephalomyelitis—I hope the following clinical anecdotes may inform this debate.2

Many patients who attend my chronic fatigue clinic had heard of or read the report. Many welcomed the official recognition of chronic fatigue syndrome as a discrete and “genuine” illness, having suffered years of doubt by others and also self doubt. The downside included the negative interpretations patients took from the report regarding the relationship between mind and body and getting better. One patient demanded to be referred to an immunologist since the government said myalgic encephalomyelitis was physical. Two others said how depressed they felt reading that there was no cure, and doubted my previous assurance that they would probably improve notably and possibly be cured. Several were confused that the report advised active rehabilitation therapies, such as graded exercise therapy and cognitive behaviour therapy, alongside the more passive approach of pacing.

I am absolutely convinced that doctors should enter into an alliance with their patients on equal terms, with one having more general knowledge and the other more personal knowledge of illness. Successful therapeutic relationships depend on each party sharing their knowledge. This is why I almost always send my patients a copy of any letter I write concerning them.3 Giving our patients the power of that knowledge allows them to share the responsibility of getting better with the doctor, rather than expecting passively applied medical miracles.

But this is power sharing, not a takeover. Takeovers produce polemic rather than a balanced view. As human beings we already make most decisions on emotional rather than rational grounds, as shown by the debate about the vaccine for measles, mumps, and rubella. As doctors we should present the rational and practical choices to our patients so they can use both the power of that knowledge as well as their own intuition to decide what is best for them and their families.

References

.A report of the CFS/ME working group to the chief medical officer. Report to the chief medical officer of an independent working group.London:Stationery Office,2002. (www.doh.gov.uk/cmo/cfsmereport/index.htm)

.Solutions to stigma: sharing knowledge with the patient: In: CrispAH, ed. In: Every family in the land: understanding prejudice and discrimination against people with mental illness.London:Royal Society of Medicine, Royal Society of Psychiatrists, Sir Robert Mond Memorial Trust, 2001. Available at: www.stigma.org/everyfamily (accessed 23 April 2002).

Are choices irrational or doctors and patients misinformed?

Barts and The London, Queen Mary School of Medicine and Dentistry, London EC1A 7BE

St James's University Hospital, Leeds LS9 7TF

Royal Edinburgh Hospital, Edinburgh EH10 5HF

EDITOR—Smith in his editorial raises many important and valid points regarding risk assessment and decision making by patients.1 We must respect the autonomy and choice of patients, an issue recently raised by the secretary of state for health, Alan Milburn, in a speech to the new health network, which stated that patients have a right to be involved in their care.2

Smith is correct in his description of risk assessment, with its complex mix of statistical information coupled with uncertainty regarding consequences. But when patients ask doctors for information to help them come to decisions, this is most often offered in terms of numerical probability information.3 Although misinformation does not necessarily result in an inappropriate or incorrect choice by patients, we must recognise difficulties in how doctors interpret this information themselves as well as its delivery and understanding by patients. The use of numerical probability information by doctors often varies because of individual interpretations of available evidence, and doctors themselves may misunderstand these numerical data.45

In view of differing information from clinicians (often misinterpreted) and coupled with patients' individual approaches to risk, it is easy to see how patients' choices might seem inappropriate. Before labelling patient choices as irrational, we must first examine how clinicians themselves understand information on probability, and whether the methods used to deliver this information to patients are effective in order to optimise patient choice.

References

.Redefining the National Health Service—Speech by Rt Hon Alan Milburn MP, Secretary of State for Health to the New Health Network. 15 January 2002. In: London:DoH,2002.www.doh.gov.uk/speeches/jan2002milburnnhn.htm (accessed 23 Apr 2002).

Personal choice yes, but not at others' cost

Barts and The London, Queen Mary School of Medicine and Dentistry, London EC1A 7BE

St James's University Hospital, Leeds LS9 7TF

Royal Edinburgh Hospital, Edinburgh EH10 5HF

EDITOR—Smith has, by accepting individual choice of medical treatment as an inevitable consequence of postmodernism, even if that choice is not based on scientific evidence, raised an important issue that threatens our publically funded healthcare system.1

Doctors have, for better or worse, accepted the role of arbiters of need using the criterion of scientific evidence of effectiveness. If I choose a treatment that is not recommended by my doctor or based on the best evidence of effectiveness can I reasonably expect other taxpayers to pay for it? And, in view of the recent evidence published in the same issue of the BMJ that homoeopathy is ineffective can taxpayers be expected to fund it?